The Minister is to be congratulated for her commitment to ensuring an end to the current arbitrary system and introducing a fair and equitable one.

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1 news Vol 2 Issue 2 September 2008 The announcement on 11 th December 2006 of the Nursing Home Support Scheme; A Fair Deal committed the Government to make residential nursing home care for older people: i i i COMMITMENTS TO OLDER PEOPLE MUST BE DELIVERED Accessible Affordable and Anxiety-free. In the words of the Minister for Health and Children the Fair Deal would put an end to the scrappy, inconsistent and unfair system that turns the issue of going into a nursing home into a trauma for them and for their family. The Minister is to be congratulated for her commitment to ensuring an end to the current arbitrary system and introducing a fair and equitable one. their public representatives. The purpose of this activity was to ensure that the legislators are fully aware of the serious concerns NHI has that the funding allocated for Fair Deal is secured for the care of older people, rather than being absorbed into the general health spend. The recently announced cuts in public spending as expected hit all areas of Government spending but the older population bore the brunt of the cuts with the majority of the fair deal money being re - absorbed into the public finances. On the 9 th July the Minister for Health and Children announced savings of 144million in the Department of Health and Children with over half of the savings made up from the delay in the implementation of the Fair Deal. Older people requiring financial support for long stay care have to wait once again as a disproportionate amount of the savings is made up of fair deal money. Inside This issue... g Integrated Discharge Planning P. 6 g Frequently asked questions P. 7 g Ensuring Equitable Access to Care P. 9 g NHI Annual Conference P. 14 The current system of eligibility for services within the health service is complex. Criteria are not always clear cut and there are inconsistencies in eligibility for certain services between different Health Service Executive regions and the public finds the present system incomprehensible and considers its outcomes unjust. Access to public funding in either public long stay facilities or private nursing homes should be based on common assessment of income and wealth. This would end the current anomaly whereby a person applying for a subvention to a private nursing home is subject to a much more rigorous assessment than a person seeking admission to a public bed. 110m was set aside in the last Budget to be spent on implementing the new Fair Deal scheme this year, but the draft legislation remains in the Office of the Attorney General. In the meantime many families, who had expected Fair Deal to be in place, have been left high and dry. On the 4 th of July, following a meeting of the Board of Directors, NHI issued a request to all members calling on them to contact their local political representatives immediately to raise NHI s concerns about Fair Deal and the protection of the Fair Deal money. In communication to members, it was made clear that it is critical that all members take action now, to contact Of the 110million provided for by the Oireachtas in budget 2008 only 25million will be spent in 2008 as follows i i the spending of 13m from the Fair Deal provision of 110m on 200 extra contract beds and the use of a further 12m of these moneys for enhanced subvention arising from increases in the cost of nursing home fees. This amount is wholly inadequate. Nursing Homes Ireland will continue to lobby and campaign for the release of the full amount of 110 million as voted by the Oireachtas to be released and spent in 2008 for services for older people. The Board at its meeting on 23 rd July, agreed that NHI use the time between now and the Autumn to plan and implement a dedicated campaign to ensure that Fair Deal is as high as possible on the political agenda when the next Dail session resumes. As well as the leadership role NHI will take in devising and implementing this activity, members have a huge role to play in supporting and advocating, particularly with their local public representatives for the implementation of the Fair Deal legislation. It is unacceptable that older people and their families, who are among the most vulnerable of our citizens, should be at the front line of spending cuts. It is time for action to ensure that the sector and older people receive the financial support required. NHI would like to thank Bank of Ireland and Homecare Medical Supplies for jointly c0-sponsoring this edition of our Newsletter. Published by: Nursing Homes Ireland Unit G6, Centerpoint Business Park, Oak Road, Dublin 12 T: (0) F: +353 (0) E: info@nhi.ie W: A significant number of companies support NHI, inclusion in this newsletter does not endorse, recommend or imply any approval of the suppliers listed in this publication.

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3 My H me Life DVD Highlighting Best Practice Initiatives to improve Quality of Life among residents in the Nursing Home Sector Help the Aged in conjunction with the National Care Forum and City University London are embarking on the development of a DVD which illustrates best practice in care homes entitled My Home Life. The DVD will be used for training purposes in the UK but it is envisioned that it will have international value. Improvements in quality of care for residents is focused on eight key themes namely Managing Transitions, Managing Identity, Creating Community, Sharing Decision- Making, Improving Health and Healthcare, Supporting Good End of Life, Keeping Workforce Fit for Purpose and Promoting a Positive Culture. Nursing Homes Ireland broadly endorsed the initiative and invited members to contribute. We would like to take this opportunity to thank all those who submitted a reflective piece and wish you every success with your contribution. Members will be kept informed of any developments. Southwest Skillsnet, in association with Nursing Homes Ireland, has expressed an interest in developing a similar DVD for the Irish market. Contact Sinéad Fitzpatrick, Practice Development Facilitator for further information on Sfitzpatrick@nhi.ie. Edited versions of some of the contributions from NHI members are included below. Pet therapy Researchers are finding that pets truly have the powers to heal their owners (Pawprints & Purrs Inc, 2008). The most serious disease for older people in long term care is often not physical its loneliness. Born on 13 th February 2004, Lee spent the first year of his life training with the Irish Guide Dogs Society. Unfortunately, due to arthritis, Lee did not make the grade as a guide dog, however, the society were anxious that Lee have a specialist placement which would benefit from his training and temperament. It is at this point Lee joined the pay roll! Lee is a highly perceptive and sensitive animal. He retains all of his guide dog commands and his demeanour is soothing and calm. Lee has an exceptional awareness of people who are ill or feeling low. If one of our residents are bed bound or spending a lot of time alone in their room, Lee will make a point of calling in for a visit and a cuddle. Lee is a source of social interaction and his party trick of sitting on his hind legs with his forelegs out stretched for a cuddle never fails to raise a smile. He is a common bond amongst not only our residents but their families and visitors also. Lee s arrival in a room relieves tension as focus is turned towards the pet. Lee is non judgemental, non medical, doesn t wear a uniform and comes full of innocence and ready to love. On July 18 th 2008, Lee was hit by a car- the residents and staff were devastated. He was rushed to the vets and after extensive x-rays, thankfully, no significant harm was done. Over the following few days, the phone lines were hopping, not with people enquiring after their relatives- but with people calling to find out how the four legged patient was doing! This instance highlighted what a truly invaluable member of the care team Lee is and just what an impact he has on the lives of those he meets. Keeping up with changing times Tom is a 79 year old man in our nursing home. He moved to here from another care facility. Tom needed long term care following major surgery and as a result of this he needed to be hooked up to an oxygen cylinder during the day time. Because of his health problems, Tom does not participate in most physical exercises although he was a good athlete during his earlier years. Amongst the visitors who frequently visit Tom are his grand children John and Sam. One day John and Sam saw our Nintendo Wii which was purchased by the home so that residents can enjoy games such as bowling, tennis etc. We asked Tom if he would like to play bowling or tennis with his grand children. Tom agreed. This has allowed Tom to have some exercise as he has to swing his arms and also he now has quality time with his grand children by sharing a game without inhibition or risk to his health. New technology has allowed Tom and his grand children to enjoy their time together and also help Tom keep fit. Little Annie Annie was reared in an orphanage having no parents or living relatives. Annie emigrated to England and was both married and widowed there. She returned to Ireland in her late seventies with only a few possessions. Unfortunately due to confusion over mislaid luggage and lack of a forwarding address Annie ended up in a psychiatric hospital. Luckily through a contact, the owners of my nursing home received Annie into our care. It took some time for Annie to regain her trust in people however once established she became immersed in the life of the home. Annie was fond of the residents; her special friends were the Alzheimer patients whom she affectionately referred to as the babies. Annie was content. She had found her family. When death finally took her from this world a member of staff was by her side. The owners of the Nursing Home buried her as if she was one of their own. PHILIP Philip was a very special man; he loved his music and often said It s my first love. How he could make that fiddle talk! On Philip s 90 th birthday, we held a surprise party for him and invited all his music friends, and everyone that knew him. Dressed up in his oversized navy suit that once fitted him, he looked so well, no pain of cancer showing that day. At three o clock friends arrived, Philip was pretty weak, so we took one side off the wheelchair to let him play the fiddle and that he did, to all our surprise. With his music friends playing alongside him, and the little Irish dancers he was so proud. He joined in all day long. The next morning when I came on duty at 8 o clock I went straight to Philips room he lay in the bed so peaceful; I thought I d leave him a while. But in a low voice I heard Good morning, I asked if he were tired and he replied yes but HAPPY, yesterday was the best day of my life, Thank you! I had to leave the room to cry. Now Philip plays the fiddle with the angels, I often think I hear him, if you listen maybe you ll hear him too! Commitment and Dedication Pays off in the end Mr D was one of the first residents admitted to a new nursing home. Mr D was very uncooperative, both verbally and physically abusive and quite aggressive but staff were aware that this was due to his condition (Alzheimers, Cognitive Impairment and Alcohol Abuse). Rendering nursing care, giving meals and administering prescribed medications seemed an endless ordeal for the staff. However because the staff stood by him (together with his family) and showed him understanding, patience and concern Mr D gradually became cooperative and manageable. He changed from being aggressive and abusive to staff at all times to a quiet, cooperative and easily managed one. I cannot help but think that Mr D s behaviour has changed a lot because of our staff s continued commitment and dedication to making him live his life just like the rest of us. Also it was and still is a learning process for us all. So the next time that we are presented with the same situation we can proudly say that yes we can. We can deal with the situation and we can make a difference in someone else s life even just for a tiny fraction. And oh, it feels so good and fulfilling. Pawprints & Purrs, Inc (2008) Pet Therapy: Healing, Recovery and Love. Accessed on Page

4 Education Days Nursing Homes Ireland ran a series of education days in May and June 2008 on Meeting the Challenges Facing Nursing Homes in 2008 and Beyond R Pictured at the NHI Education Day in the Louis Fitzgerald Hotel, Dublin on the 17 th of June were Amber Dungan- Membership Liaison and Communications Manager NHI, Caroline Connelly- Practice Development Facilitator NHI and Sinéad Fitzpatrick,Practice Development Facilitator NHI R Pictured at the NHI Education Day in the Louis Fitzgerald Hotel, Dublin on the 17 th of June were Avril Dooley - Advocacy Officer, Age Action Ireland, Ciara Hopper Director of Nursing,TLC Centre Santry and Residents and Care Staff of TLC Centre Santry. NHI s highly successful Education Days were An Bord Altranais Category 1 approved and certificates of attendance were issued to all attendees. These days, were well attended by staff of Private and Voluntary nursing homes, and our colleagues from the HSE and HIQA. The days were held in Galway- 29th May, Cork 11th June and Dublin 17th June, attracting an attendance of 234 delegates nationwide. The success of the days were further highlighted by excellent evaluations from attendees and local media attraction. I d also like to thank the sponsors and exhibitors who ensured that the days were free of charge to all Nursing Homes Ireland members. These days were organised by Caroline Connelly NHI Practice Development Facilitator and had key national speakers presenting on pertinent topics and issues that nursing homes are currently facing and addressing. g From HIQA and the Social Services Inspectorate were presentations from Dr Marion Witton Chief Inspector, Michele Clark Deputy Chief Inspector and Anne Ryan Inspector Manager who gave excellent presentations on HIQA and the Quality Standards and helped to allay some of the anxieties nursing home staff are experiencing. g Dr Helen Flint Presented on Medication Management. g John Sweeney from Health Care Informed presented on implementing the HIQA Quality Standards. g Ann Coyle HSE Planning Specialist presented on the Teaghlach Initiative. And Margaret Buckley from the NMPDU in Cork presented on the Person Centered Practice Initiative. g The Healthy Aging Initiative was presented by Ann O Riordan from HPH- Health Promoting Hospitals and Olga McDaid from the NCAOP - National Council on Aging and Older People. g Clodagh Cooley and Geraldine Lynch updated us on Palliative Care and a new training initiative for Nursing Homes. g An update on the HSE National Policy on Restraint was given by John Linehan from the HSE South. g Elder abuse and statistical information on the numbers and types of abuse reported in Ireland was given by Bridget McDaid Dedicated Officer for Elder Abuse HSE West. g Residents Councils and Residents Advocacy were presented by Carmel Sheridan - Age Action West and Avril Dooley - Age Action in Dublin, and the residents from TLC Nursing Home in Dublin and the Staff, Relatives and Residents of St Luke s Nursing Home in Cork. The presentations on Resident s Committees by the residents of St Luke s and TLC were an inspiration to us all with many delegates commenting that these presentations were the highlights of the days. A further day was held in Cork on Nursing the Resident with Dementia and was again An Bord Altranais Category 1 approved. The presenter was Mary Mannix, Clinical Nurse Specialist. And again this was well attended and highly evaluated by all. The first set of Education Days on the NHI Assessment and Care Planning Integrated Resident Record given by John Sweeney and Caroline Connelly were very well received with large attendances and very good evaluations as reported in the last edition of Nursing Homes Ireland News. We received many requests to put on further days and an extra day was held in Kilkenny on the 8th of July, chaired by Anne Fleck Byrne NHI Director in the South East. The day had a very good attendance of over 80 attendees and was a great success. As you are all aware I left my position of Practice Development Facilitator with Nursing Homes Ireland at the end of July. You may be aware that the Post was a two year contract Part Funded by The National Council through the Nursing and Midwifery Planning and Development in the South. Nursing Homes Ireland committed to continue the Practice Development Role at the end of the project and I am delighted that Sinéad Fitzpatrick took up her post as NHI s new Practice Development Facilitator in June and I want to wish her all the best in her role. I would like to take this opportunity to thank the NHI Board, the Nursing Committee, the Staff of NHI, the Chairman and CEO Mr. Tadhg Daly for all their support of my role, and I would like to thank all the members of NHI. It has been a pleasure working with you all and I wish you all the best in the future. Caroline Connelly Former Nhi Practice Development Facilitator Page

5 Nursing Homes Ireland Nursing Committee News The Committee was formed in January 2008 and consists of 1 representative and 1 nominated alternative from each of the 10 regions of the country. The following regions, based on the geographic boundaries of the former health boards, each select a single member to the Nursing Committee: Dublin/ Kildare Maura Galvin Padre Pio Nursing Home, Cappaghmore, Co. Dublin mauraglvn@yahoo.ie Dublin North Catherine Dunleavy Tara Wintrop Private Clinic, Swords, Co. Dublin dunleavyc@tara-winthrop.com Dublin/ Wicklow Margaret Wafer Belmont House Nursing Home, Stillorgan, Co. Dublin info@belmontcare.ie West Aideen Stanley Caiseal Geal Nursing Home, Castlegar, Co. Galway ajstan@iol.ie South East Jimmy O Keefe Borris Lodge Nursing Home, Borris, Co. Carlow jimmy@borrislodge.ie North West Marie Fitzpatrick St Eunan s Nursing Home, Letterkenny Co. Donegal dmfitzp@gofree.indigo.ie South Catriona O Connor Cuil Didin Residential Care, Tralee, Co. Kerry catriona.oconnor@cuildidin.ie North East Helena Moore Kilbrew Nursing Home, Ashbourne, Co. Meath helenab44@eircom.net Mid West Catherine Quealey Villa Maria Nursing Home, Roscrea, Co. Tipperary catherinequealy@eircom.net Midlands Paula Gavagan St. Clair s Nursing Home, Ballinderry, Mullingar, Co. Westmeath pgavagan@stfrancishospital.ie Nursing Homes Ireland Sinéad Fitzpatrick Practice Development Facilitator NHI sfitzpatrick@nhi.ie The Committee produced an action plan for 2008 which included two key objectives to meet the HIQA National Quality Standards for Residential Care Settings for Older People in Ireland. They are as follows: 1. Assisting Member Nursing Homes to develop Purpose and Function documents under Section 2 Governance and Management (section 7 standard 27 and 28), of HIQA National Quality Standards for Residential Settings for Older People in Ireland. 2. Assisting Member Nursing Homes to Develop/Access an Advocacy Service under Section 1 Rights (standard 3, consent 3.5) of HIQA National Quality Standards for Residential Settings for Older People in Ireland. Sinéad Fitzpatrick, Practice Development Facilitator produced a Purpose and Function template for local adaptation which was agreed by the Committee and has been sent out to all members for use. Sinéad also drafted two lists of recognised advocacy services in Ireland both externally and internally of nursing home settings which were distributed to all members. The Committee have also made two submissions to the consultation processes on HIQA Draft Infection Control Guidelines and the HSE and Irish Hospice Foundation Palliative Care For All documents. The submissions are available on the NHI website. The Nursing Committee are in the process of sourcing clinical policies and procedures for our members. It is envisaged that strategic partnerships and/ or sign posting of policies would be developed to allow members to access evidenced based policies as a reference to creating their own policies. It has been agreed at the meetings that it would not be in the remit of the Nursing Committee or the Practice Development Facilitator to develop all policies and procedures for our members. This is due to time constraints and the need for individualised policies which reflect the environment and staffing situation within each member home. Sinéad Fitzpatrick represents NHI on a working group to develop Nutrition, Hydration and Dysphagia policies and guidelines in conjunction with Fresenius Kabi. Other members of the group include Margot Brennan, President Irish Nutrition and Dietitics, a Dysphagia chef, a CNS in Nutrition and Speech and Language therapists. The policies and guidelines are to be launched together with a training package at three designated education days scheduled for 23 rd September at Citywest Hotel, Dublin; 30 th September at Maryborough Hotel, Cork and 9 th October at Claregalway Hotel, Claregalway. Page

6 Integrated Discharge Planning If we are to truly support the delivery of integrated care, then a particular focus must be the development of routine practices and procedures to facilitate integration across services and over time. Of particular importance are transition points across the health system. The transition that has received the most focus is the transfer from hospital care to the community. Effective discharge planning that integrates care pathways into the community is imperative to reorienting practice from discrete and isolated interventions toward integrated and continuous care. Discharge from a hospital is a process, not an isolated event. It involves the development and implementation of a plan to facilitate the transfer of an individual from hospital to an alternative setting where appropriate. Components of the system (individual, family, carers, hospitals, primary care providers, community services and social services) must work together to ensure an integrated person centred approach and best outcome for the individual. The discharge process perhaps can be considered as a lens through which we can focus our attention on the internal organisation factors within hospitals that influence lengths of stay, bed occupancy, bed utilisation and also draw clear attention to the nature, capacity and availability of community based services to be proactive and responsive in order to avoid unnecessary admissions to acute care and to facilitate earlier discharge. To date there has been a number of blockages and obstacles which have held back improvements in the discharge process which need to be addressed in a systematic and structured way if we are to improve. Some of these include: g clinical management plan does not include expected date of discharge (EDD) based on an anticipated length of stay (LOS) resulting in: i discharges mainly happening in the afternoon i fewer discharges over the weekend and bank holidays i patients staying longer in hospital than clinically necessary g no framework to plan the discharge g lack of clearly defined roles and responsibilities amongst multi-disciplinary team around management of discharge g multi-disciplinary team unclear about knowledge, skills and competencies needed to support discharge decisions g feelings that nurse initiated discharge is too risky or concerns about patient safety From the point of view of improving overall bed availability the development of a strategic approach to discharge planning has been advocated by many recent reports and the national and international research is clear. We do not have to reinvent the wheel on this one! The Evidence and Signposts: One of the most effective strategies for reducing total patient journey time is to focus on the bottlenecks in both the admission and the discharge process. A mismatch between variation in demand (admissions) and the variation in capacity (resulting from discharges) gives rise to queues and waiting lists. The greatest variation is typically in the number of discharges carried out. The main cause of this variation has been identified as the way in which hospitals manage issues such as ward rounds, ward processes, inpatient tests and results and pharmacy. The result of this is a highly variable and unpredictable length of stay. The Acute Hospital Bed Review 1 found that discharge planning was in evidence from the notes of only 40% of all patients surveyed and only 17% had a predicted discharge date. The Secta report concluded that there is not consistent application of national admission and discharge advice, contributing to unnecessary variability in patient management within and across hospitals. From the point of view of improving overall bed availability focusing on patients with simple discharge needs is likely to have the greatest immediate impact because, critically g the numbers of patients which can be impacted are very large (at least 80% of discharges are simple) g the actions needed do not usually require any other agency s involvement to succeed Key points identified for reducing delay include: g All patients should have a treatment plan within 24 hours of arrival in hospital. g An expected date of discharge should be set within 24 hours of arrival or in many cases before admission for elective patients and communicated to the patient and all staff in contact with the patient. g The expected date of discharge should be proactively managed against the treatment plan (usually by ward staff) on a daily basis and changes communicated to the patient. g Ward rounds should be scheduled in a way that allows, at least daily, a senior clinical review of all patients. g Internal hospital processes should be reviewed to reduce delay eg patient assessment, access to diagnostics. g Protocol based discharge planning and use of estimated dates of discharge should be implemented. g There should be a national focus on simple discharge process in all hospitals. National guidelines should be adopted, reviewed and built into a robust clinical governance process across each organisation and the system as a whole. it is not the complex nature of the patient condition or the fact that the patient is old or lives alone but the way local health systems are configured to treat and care for the patient that results in inappropriate occupancy of an acute bed. 1 Various surveys of patients themselves have also confirmed problems with the discharge process with the majority of patients being given notice of discharge only on the morning of discharge: and even when this notice is given there are still further waits:-waits for GP letters, waits for certs for work, waits for prescriptions, waits for follow up appointments etc 3! Breaking New Ground: The HSE has over the past eight months engaged in a comprehensive process of literature review, key stakeholder consultation, workshops and focus groups which has informed the development of a National Code of Practice for Integrated Discharge Planning. The Code of Practice will provide a framework within which efficient care and case management can be delivered and providing clarity on key roles, responsibilities and performance standards. The Code comprises a suite of national standards, recommended practices, forms, toolkits, key metrics and audit tools covering the following areas: g Communication and Consultation g Organisational Structure & Accountability g Management & Key Personnel g Education & Training g Operational Policies & Procedures for Discharge Planning g Discharge Planning Process g Audit & Monitoring g Key Performance Indicators The implementation of the Code of Practice is scheduled to commence in the early Autumn and will help address many of the impediments to improved practice mentioned earlier ensuring; g that all patients will have a treatment plan and an expected date of discharge/ estimated length of stay within 24 hours of arrival into hospital. g that the expected date of discharge is proactively managed against the treatment plan on a daily basis and changes are communicated to the patient. g that ward rounds are scheduled in a way that facilitates appropriate and timely clinical review of all patients and efficient care processes. g the introduction of a comprehensive and standardised Discharge Summary which will be available to patients, their carers and other relevant care providers such as GP s, Pharmacists, Nursing Homes once the patient is deemed fit to leave hospital. g ensuring that discharges take place on Saturdays and Sundays at the same level as on other days of the week g facilitating nurses and other members of the multi-disciplinary team to play a more central role in discharging patients from hospital once criteria set out by medical staff are met This is but one of a number of targeted initiatives that can deliver upon the transformation of our health services. By William Reddy, Programme Manager, HSE 1 Acute Hospital Bed Review: A review of acute hospital bed usage in hospitals in the ROI with an Emergency Department (PA Consulting 2007) Page 2 Tribal Secta Report, The Way Forward HSE The Patients View (ISQSH) 2005

7 When will the Fair Deal actually come into effect? Please see below response from the Department of Health and Children, on behalf of Minister Mary Harney, on the 17 th of July 2008 confirming the Ministers commitment to introduce legislation in the forthcoming Dail session which commences on 24 th September 2008 The legislation required in order for the Nursing Home Support Scheme, A Fair Deal, to commence is at a very advanced stage and the Minister is confident that the Bill will be ready to be debated as soon as the Dail resumes after the current recess. She will be bringing the draft legislation to Government as soon as possible to enable this to happen and to allow for publication of the Bill in advance of debate in the Oireachtas. Please also see below Press Statement 14 th July 2008 from Department of Health and Children: Fair Deal to be implemented in 2009 Minister Hoctor The Minister of State for Older People, Máire Hoctor T.D., re-iterated that the Fair Deal scheme will go ahead in 2009, subject to Oireachtas approval. The Fair Deal was approved as Government policy in December It was reaffirmed in the Programme for Government. It remains Government policy. All the preparations are being made to ensure it is put on the most robust legal footing and will proceed in 2009, once enacted by the Oireachtas. Last week, Minister Harney said that the Bill to provide for the Fair Deal will be ready for debate in the Oireachtas when the current recess is over. She will be bringing the draft legislation to Government as soon as possible to enable this to happen and allow for publication of the Bill in advance of debate in the Oireachtas. Minister Hoctor also stressed that there would be a conferral with the social partners, under the auspices of Towards 2016, as soon as the Bill is published. Will HIQA be inspecting public nursing homes? Yes. The Minister, Department of Health and Children and HIQA have committed to the inspection of all public, private and voluntary residential care settings for older people as dictated in a press release on 11 th March This information is also included in the Draft National Quality Standards for Residential Care Settings for Older People in Ireland (page 5) and the Health Act Nursing Homes Ireland along with other key stakeholders for care of the older person are committed to ensuring the implementation of both registration and inspection for all public, private and voluntary nursing homes. When will HIQA commence inspections? NHI requested an update on the current status regarding the methodology for inspections and also HIQA proposals, including locations and timeframe, in respect of pilot inspections. Frequently Asked Questions In a response letter from Michele Clarke - Deputy Chief Inspector HIQA, received 3 rd June the following was stated. Work on developing the registration and inspection methodology is on-going and in part, this is dependent on what will be contained in the regulations to be developed by the Department of Health and Children. The piloting exercise can only take place following the recruitment and training of inspectors. For that reason HIQA envisage that the piloting of the registration process is unlikely to take place until the beginning of In relation to locations for the pilots, HIQA will most likely ask for volunteers from each of the sectors, public, private and voluntary, from which they will select one for each pilot. In HIQA s view the pilot will be of most value where they inspect against types of residential centres regarding size, function and location. As HIQA did with the public consultation process, they will talk to NHI and the HSE nearer the time to put forward names of those willing to take part in the pilot. What is the Regulatory Impact Assessment (RIA), in relation to the HIQA Standards? NHI have been in contact with the Dept. of Health and Children in respect of the proposed new HIQA Standards. The Standards have been submitted to the Minister for Health and Children and are subject to a regulatory impact assessment (RIA) by the Dept. Once the regulations are in place, the Social Services Inspectorate of the Authority will register and inspect all residential care settings, public, private and voluntary, against the National Quality Standards for Residential Care Settings for Older People in Ireland, and the regulations. In a response from Geraldine Fitzpatrick, Department of Health & Children on the 30 th of June the following was stated: The present position is that the RIA has commenced. The Department of Health & Children are in the process of consulting other government departments etc. and hope to have the Request for Tender for the cost benefit analysis piece published in the next 2 weeks. The Minister has promised that stakeholders will be consulted about this matter in general and the Dept. are looking at venues for September/October. Can HSE nursing home inspectors currently inspect against the Draft National Quality Standards for Residential Care Settings for Older People in Ireland? No, the HSE will continue to inspect against the Nursing Home Care and Welfare Regulations en/si/0226.html until the draft National Quality Standards for Residential Care Settings for Older People in Ireland are legislated for, by way of new regulations by the Minister for Health and Children Mary Harney TD. The Department of Health and Children are undertaking a Regulatory Impact Assessment together with a Cost Benefit Analysis. The new regulations will be drafted and the Minister for Health and Children has committed to consultation with Nursing Homes Ireland on the new regulations. When the standards are drafted and subsequently legislated for through the Dail, HIQA will take over the remit of inspections from the HSE. This process is unlikely to take place until 2009 at the earliest. Until such time inspectors cannot inspect using the draft standards as the draft standards are not legislated for and are not enforceable. What is the Minister for Health and Children s response to the draft HIQA Standards and their implementation? Please see below quote from Minister Harney at the Oireachtas Committee on Health and Children on 18 th June: With regard to residential standards, those standards are draft standards from HIQA and are currently the subject of a regulatory impact assessment. The standards are a matter for the Minister to sign off on. I am conscious of some of the issues the Deputy raises. There are two different issues. One is the quality of care, on which there can be no compromise. The second is the environmental issue, such as size of rooms and so on. We need to move in an incremental fashion. We cannot move today to a situation that may be desirable eight or ten years from now. I do not know what regulatory impact assessment will be made, I have physically visited nursing home rooms that I would regard as being of a good standard if I had relatives in those rooms, and I have been really satisfied with the quality of care in the facility, but it would not meet the standard. In all we do, we are talking about incremental improvements but there can be no compromise on the quality of care. Can I employ a nurse who is not on the general nursing register with An Bord Altranais in my nursing home? As long as you can provide a scope of practice for the staff member to take into consideration their training, expertise and competencies there is no valid reason to prevent you from doing so. It must be highlighted however that best practice would indicate that these nurses should not be the sole nurse on duty for general nursing homes. The previous Person In Charge removed the self closing mechanisms on all our residents room doors as she felt they were a contributor to the incidence of falls within the home. The fire officer thinks I may now be in breach of fire regulations. What should I do? There is no reported evidence of self closing doors contributing to patient falls recorded, and any information relating to this appears to be anecdotal. There is a requirement in legislation for all fire doors to have a self closing system in place. Check with your local fire department for further information or for a review of your Fire Safety Certificate. Where can I access Gerontology courses? Post graduate courses are run via NUI Galway, Trinity College Dublin and Athlone Institute of Technology. Please follow links below for more information: Private healthcare skillnet also provides access to these courses: Our Lady s Hospice in Harold s Cross provides access to both post graduate courses and a range of introductory and best practice days in Gerontology. For further details follow the link below: La Touche training provides a one day introductory course on care of the older person. See below: files/1/care%20of%20the%20older%20perso n.pdf Please go to the FAQ Section on our website to also access above links. What legislation or guidelines should I consider when writing a confidentiality and record keeping policy? Data Protection Act An Bord Altranais Recording Clinical Practice Guidance to Nurses and Midwives Powers of Attorney Act Records Retention Policy HSE Guidance on Electronic Records All of the above can be found in the members section of the Nursing Homes Ireland website. Page

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9 An Update on The Forum on Services for Older People New Proposals for National Advocacy Programme in Residential Homes Services - PCCC). The Forum for Older People was established in late 2006 under the auspices of HSE s Office of Consumer Affairs. It comprises almost all of major national organisations with a special interest and expertise in services for older people including: Department of Health & Children, HSE, National Council for Ageing & Older People, Nursing Homes Ireland, Irish Hospice Foundation, Citizens Information Board, Age & Opportunity, Age Action Ireland, Alzheimer Society, Irish Society for Quality & Safety in Healthcare, Irish Advocacy Network, Patient Focus, Senior Helpline, Third Age, Irish Patients Association, and the Irish Senior Citizen s Parliament. A uniform approach to the assessment of need for long term residential care has been adopted by the HSE. A national project team, led by Cate Hartigan, was established last year to lead on the development and implementation of the Common Assessment Process (CAP). Admission to Continuing Residential Care is a significant life decision and should only be taken when all other care options have been exhausted. In order to ensure appropriate placement, each person should have a comprehensive assessment as soon as possible before a decision on care placement is made. The Common Assessment Process (CAP) was developed based on the Expert Advisory Group Policy Document Clinical Pathways to Long Term Residential Care. In simple terms, this means that all applicants for residential care should, where resources allow, have had a multi-disciplinary assessment with Geriatrician/Psychiatrist of Old Age input before a decision is made on the need for long term residential care. The Common Assessment Process (CAP) must be supported by arrangements that enable community and hospital based applicants to receive equitable access to care. By Kieran McKeown/ Anne Harris (Project Manager) R From left to right: Graham Long (CIB); Jackie Ebbs (Specialist Older Person s Services/ EAG); Declan Hynes (HSE Performance and Development); Anne Harris (HSE Consumer Affairs); Linda Desmond (Age Action Ireland); Sinéad Fitzpatrick (NHI); Mary Byrne (Admin Support -HSE); Michael Brophy (Irish Centre for Personal Excellence/ Consumer); Bob Carroll (NCAOP); Paschal Moynihan (Specialist Older Person s units. The first proposal is for the development of a unified source of information on all long-stay residential care services - public, private and voluntary - to assist older people, their families and carers when faced with the need to choose a long-stay home. The second proposal is for a representative advocacy service for older people in long-stay units. The third proposal is for the development of training and mentoring programmes in residential units which will strengthen leadership at senior management level and cultivate an ethic of excellence among all staff. To date funding has been received from the Health Services National Partnership Forum and from the Innovation Fund which has enabled the programme to commence. Primary, Community and Continuing Care, the National Hospitals Office and the Department of Health and Children have been asked to delegate representatives to the The Forum for Older People is one of a number of initiatives which has been developed under the National Strategy for Service User Involvement *Dr. Kieran McKeown is a social and economic in the Irish Health Service a national research consultant, and the facilitator of the transformation project. Forum. The Forum developed three proposals for service * *Anne Harris is the project manager and developments which could dramatically improve may be contacted at anne.harris1@hse.ie or the quality of life of people living in residential 045/ Ensuring Equitable Access to Care To quote from the Expert Advisory Group document: There should be one standardised process across the country to access long stay beds and not a two tier system whereby older people in acute hospitals are given priority over older people living in the community. The Common Assessment Process (CAP) was developed in anticipation of the new nursing home support scheme A Fair Deal for which legislation is currently being drafted. A Common Summary Assessment Record (CSAR) has also been developed as a standard national document to record the outcome of assessments. Following extensive national consultation, including pilots in nine acute/ community settings at the end of 2007, the first version of the new national Common Summary Assessment Record (CSAR) was signed off by the HSE early this year. The introduction of a common assessment approach is based on best practice and is not dependant on the Fair Deal legislation being enacted. The HSE has therefore adopted the Common Assessment Process (CAP) and the associated Common Summary Assessment Record (CSAR) as national policy with immediate effect, to be fully implemented by the end of This is to be applied wherever the HSE financially supports care, be that through subvention, private nursing home placement or placement within public or voluntary units. National Advocacy Programme and they will be joined by a number of individuals from the original sub-groups to ensure continuity. The first piece of work already conducted was a baseline survey of current services available and in this way a benchmark is maintained for further evaluation. Expressions of interest will be sought for this part of the process as for the provision of development officers and it is anticipated that the programme will last a period of eighteen months. Following the development phase it is hoped that the programme will be integrated into all community units and nursing homes in the country. Ultimately, the combination of Service User Involvement and the National Advocacy Programme should ensure that health services anticipate problems early, avoid complaints, develop appropriate and effective service provision and guarantee that service users will be at the centre of efforts to drive up the quality and safety of service provision. We would like to thank Dell Ireland Ltd. and Harmonia Press for offering prizes to those completing the questionnaire. Nursing Homes Ireland is represented by Sinead Fitzpatrick, Practice Development Facilitator. For further information contact sfitzpatrick@nhi.ie Local Implementation: A national work plan for the implementation of Common Assessment Process (CAP) and Common Summary Assessment Record (CSAR) has been agreed and a roll-out in all 32 Local Health Offices and Acute Hospitals is currently in progress. Currently each Network Manager and each Local Health Manager is nominating a lead person to implement the Common Summary Assessment Record (CSAR) and associated processes in their area of responsibility. These leads are being asked to action local implementation plans with support from the National Project Team. Longer Term: When the Fair Deal legislation is enacted the Common Assessment Process (CAP) will be reviewed to ensure that HSE is in compliance. The Common Assessment Process (CAP) and Common Summary Assessment Record (CSAR) will be reviewed six months after implementation. It is already recognised that not all areas have access to Multi Disciplinary Teams and/or Geriatricians/Psychiatrists of Old Age and this will be addressed over time. In addition a working group is currently being established to develop a standardised, valid and reliable Single Assessment Tool associated to assess the need for care. Cate Hartigan - Project Manager Common Assesment Process (CAP), HSE Page

10 Bridging the Generation Gap Back in June one of Tralee s best-known residential homes for older people launched an art competition for schools which aimed to challenge the perceptions young people have of older people. The event, organised in conjunction with Kerry s Eye, was part of the Bealtaine festival, which ran throughout the month of May and celebrated creativity in older age. Director of the Cuil Didin nursing home in Tralee, Catriona O Connor, said at the time of the launch that the competition will involve primary schools in the Tralee area. The aim is the allow young people to express what older people mean to them. It could be a painting, a sketch, an artistic piece or any form of artwork which illustrates that young person s perceptions of older people. The objective is to bridge the generation gap a bit between the younger and older generations, she said. We wrote to all the schools in the greater Tralee area to invite entries for the competition and had a prize-giving for the winners. We would also hope to display the winning entries here in Cuil Didin, she said. Taking its name from the ancient Celtic Festival, Bealtaine celebrates renewal, creativity and growth in ageing. A whole range of activities are currently taking place around the county which are aiming to promote greater participation by older people in society. Pictured above is Caherleaheen School the proud winners of this competition along with, judges, and staff and residents of Cuil Didin Nursing Home. NHI Staff Changes Nursing Homes Ireland are pleased to introduce two new members of staff to our organisation since the publication of the last newsletter in April. Amber Dungan - Membership Liaison and Communications Manager Amber joined the organisation on the 3 rd of March She holds a BA (Hons) Degree in English from University College Dublin and a Diploma in Event Management- Modules in Marketing and PR from the Fitzwilliam Institute. She also achieved a Certificate in Essential Skills of Management with the IMI (Ireland s Executive Management Centre) Having previously worked in Newlands Golf Club as Golf Operations and Membership Administrator for almost three years her background is administrative, marketing and communications based, having also applied her skills to other industries including IT and media. In NHI, in addition to her responsibilities of management and supervision of the administration staff her main responsibility is one of maintaining the integrity of all information relating to members, managing current membership and the membership development process. In addition she provides a valuable central administrative support for the Board of Directors, the CEO and other Committees. Having successfully undertaken the co-ordination of the publication of the first NHI newsletter in April she continues to undertake this responsibility and hopes all forthcoming newsletters will be as successful as the first. Amber is based at Head Office and can be contacted via amber@nhi.ie or at Sinéad Fitzpatrick Practice Development Facilitator Sinéad joined the organisation on 3 rd June She holds a B.Nurs (Hons) degree, Community Nursing in the Home (District Nursing) and ENB Teaching and Assessing in Clinical Practice post-registration qualifications. She has also completed a management course and two Cancer Nursing modules at level three at Manchester University and has experience of implementing the Liverpool Care Pathway for End of Life care within the district nursing service. Sinéad was also a registered nurse prescriber in the UK but this qualification has yet to be recognised in the Irish health system. Sinéad worked as a District Nurse for eight years within the North area of Manchester mostly in a managerial capacity. During this time Sinéad was involved in several clinical governance initiatives which included development and ratification of clinical and non-clinical policies, procedures and protocols; chairing and organisation of the District Nursing Forum; development of an induction programme and clinical competency framework for new staff; adoption of new clinical practices and the coordination of associated training, education and risk management processes which resulted from this. She also facilitated the clinical training and mentoring of an Assistant Practitioner to perform nursing skills within a nationally recognised scope of practice. Sinéad is currently representing Nursing Homes Ireland on a number of working groups which include Elder Abuse National Interest Group, HSE-National Wound Care Guidelines group, Dementia Steering Group, Forum for Older People, Palliative Care Education in Nursing Homes, Pharmaceutical Society of Ireland Focus group, Nutrition and Dysphagia policies working group, Falls Steering group and the Minimum Data Set Interest group. She also provides clinical advice, support and training for all members of Nursing Homes Ireland and is working on a number of templates which can be individualised and adopted into clinical practice within your own nursing home environment. Current templates include a Purpose and Function booklet as required under standard 28 of the HIQA National Quality Standards for Residential Care Settings for Older People in Ireland; an Induction programme for staff and a proposed Incident Reporting System to promote patient safety and highlight key themes which are common among nursing homes in Ireland. Further information on Sinéad s role is included within this newsletter. Sinéad is based at Head Office and can be contacted via Sfitzpatrick@nhi.ie or on her mobile Fond Farewell Deirdre Lynch left on 13 th June following 4 years of service with Nursing Homes Ireland and previously with the Irish Nursing Homes Organisation. Deirdre joined the Irish Nursing Homes Organisation on 25 th July 2004 Angela Lowe left on 16 th July following 7 years of service with Nursing Homes Ireland and previously with the Federation of Irish Nursing Homes. Angela joined the Federation of Irish Nursing Homes on 22 nd October 2001 Caroline Connelly (Practice Development Facilitator) left on 1 st August following 2 years with Nursing Homes Ireland and previously the Irish Nursing Homes Organisation. Nursing Homes Ireland would like to take this opportunity to sincerely thank the aforementioned staff for their hard work, dedication and commitment both to the organisation and for their service to all members. We wish them all success and happiness in their future roles. Page 10

11 Pharmacy Ireland 2020 Interim Report Deliver Better Patient Care and Added Value Services The Pharmaceutical Society of Ireland (PSI), the pharmacy regulator, presented its Interim Report on the future of pharmacy services in Ireland to the Minister for Health and Children on 30 April. This Interim Report, based on a discussion paper prepared by the Clinical Pharmacy Practice Research Group at the School of Pharmacy in UCC, reviews pharmacy services currently provided in Ireland and compares this with best practice in other countries. Pharmacy services in other countries use evidence based approaches to provide enhanced services to patients and costeffective solutions to the challenges faced by health systems. The Interim Report outlines the potential of pharmacists as highly accessible, frontline healthcare professionals to develop services that could free up resources elsewhere in the health system and maximise patient gain. Among the elements examined in the report are chronic disease management and screening; pharmaceutical care and medicine use reviews; a minor ailments scheme; recategorisation of medicines; prescribing authority for pharmacists; pharmacy vaccination clinics; pharmacy and drug safety and the role of clinical pharmacists in hospital pharmacy. g The management of chronic diseases is one of the most significant challenges facing the health system. As pharmacists are the healthcare profession with the most frequent contact with patients living with chronic diseases, most of which are managed with medication, the report advocates a greater role for pharmacists in managing these patients. Evidence from other countries, for a range of conditions including diabetes, heart failure, cardiovascular disease and chronic obstructive pulmonary disease, points to cost-effective clinical benefits of structured pharmacist involvement in the management of these patients. g The report also suggests that the accessibility of the current community pharmacy network in Ireland, with the average community pharmacy in Ireland open 50% longer than GP clinics, provides the basis for the development of structured population health screening initiatives. g Medication management and medicine use reviews (MURs) have significant benefit for patients, in ensuring they receive the best therapy possible in compliance with internationally accepted guidelines, that all patients receive optimal therapy and that the process is quality assured and validated. The Oireachtas Joint Committee on Health and Children s Eighth Report on The Adverse Side Effects of Pharmaceuticals, published in April 2007, recommended that the role for the R Pictured at the PSI Pharmacy Ireland 2020 Interim Report launch (l-r) Prof Julia Kennedy (UCC), Dr Mark Ledwidge(UCC), Minister Mary Harney, PSI Vice-President Brendan Hayes and Prof Peter Weedle (UCC). pharmacist in community health should be expanded and provision made for regular medication reviews for all patients, and this recommendation is endorsed in the PSI report. g Community pharmacists deal routinely with minor ailments every day and their role in the management and treatment of minor ailments and in the provision of professional advice on self-care is an important part of the primary health care process, points out the interim report. The implementation of a National Minor Ailments Scheme, making pharmacy the first port-of-call for minor ailments, would benefit patients by providing greater access to healthcare advice, and would benefit the health service by targeting resources and making savings which can be redistributed. For example, it would reduce the burden on GP surgeries where an estimated 18% of time is spent on these ailments. g The switching of medicines so that they are more readily accessible to patients could be facilitated by the introduction of a new legal category pharmacist prescribed, suggests the report. This would require the pharmacist to carry out a number of clinical checks and record details of the consultation so that certain medicines would be supplied more safely with more structured counseling and monitoring. g Avoidable medication errors occur every day and the role of the pharmacist in minimising drug errors has been shown to be both clinically and cost effective. As the evidence-based drive to greater polypharmacy results in greater drugdrug and drug-disease interactions, the pharmacist s role in pharmaceutical care of patients should be recognised and developed. The pharmacist could also play a more central role in adverse drug reaction (ADR) reporting, which currently in Ireland is significantly under reported. g The report suggests that prescribing authority should be extended to pharmacists with appropriate training and competence development, and highlights that such an initiative would need to be supported by a system enabling healthcare professionals access to integrated patient medication records (PMRs). g Pharmacy vaccination clinics provide a convenient, accessible location for the delivery of immunisation programmes in several countries, and in particular for the seasonal influenza vaccination campaign. In addition, in preparing for a global pandemic, contingency plans need to include resources for immunising large numbers of people in a short timeframe. While most of the report focusses on the potential for enhancing services in community pharmacy, it also notes the development of the clinical role of hospital pharmacists which provides significantly improved patient care, as well as cost savings. Speaking at the launch of the report, the PSI s Registrar and Chief Executive, Dr Ambrose McLoughlin said: Pharmacy services in other places, for example Scotland and New Zealand, are adding significant patient value. Most jurisdictions, including the UK, are utilising evidencebased approaches in the reform of their services, with pharmacy seen to have increasing potential to support home care, self care and effective care at the lowest levels of cost and complexity. Since the publication of the Interim Report, the PSI has continued to receive submissions and a final report will be produced at the end of the year. As part of its ongoing consultation, the PSI is also holding a number of focus group sessions with key patient and other healthcare stakeholders. Nursing Homes Ireland has already participated in this process with a number of other patient support and care organisations. The PSI is also exploring the economic impact of the changes envisaged in the Pharmacy Ireland 2020 initiative as part of the process to chart a future course for pharmacy in Ireland to provide better care and services to patients. The Interim Report can be downloaded from the PSI website ie/news/latest_news/psi_publishes_ Report_ on_ Developing_ Pharmacy_ Services.html. For more info please contact Kate O Flaherty, Head of Communications and Public Affairs, Pharmaceutical Society of Ireland kate.oflaherty@pharmaceuticalsociety.ie, phone: Page 11

12 NHI Presentation to Joint Oireachtas Committee on Health and Children To ensure that NHI keep the pressure on the fee increase for 2008 and on the Fair Deal we have communicated with opposition spokespersons on health and the Joint Oireachtas Committee. The Joint Oireachtas Committee on Health and Children met on Thursday 8th May to discuss the health estimates. NHI lobbied Deputy James O Reilly and Deputy Jan O Sullivan to raise this issue at the Joint Committee and to elicit answers assurances were given stating that the money set aside for Fair Deal is ring fenced. NHI requested an opportunity to present to the Joint Oireachtas Committee on Health Alzheimer s Kayleigh Lloyd Harris at the 2008 launch Cheers for your support! 2008 Alzheimer s Tea Day 2008 really was the Big Brew with more people than ever taking time out to make their cuppa count! Whether you hosted or attended a tea break - at home, at work or someplace quite extraordinary, sold raffle tickets or forwarded a donation, we d like to say a huge THANK YOU! This year, our 14 th Alzheimer Tea Day we had over 1607 hosts, with parties taking place all over the country, including our host sponsors Nursing Homes Ireland and Celtic Bookmakers. In total, 51 nursing homes held Tea Parties this year. As always all monies raised in your region go towards local services for local people with dementia and their carers. With money still being counted from the big day, the final figure hasn t been tallied yet, but it looks like this has been our biggest brew to date! The Tea Day Raffle Prize Winners were as follows: 1 st Prize: Kathleen Maher from Tipperary 2 nd Prize: Teresa Devin from Louth 3 rd Prize: Monica O Reilly from Cavan and Children and were invited to do so at the Committee meeting on the 3rd of July, where the issue of the Fair Deal would be on the agenda. We also formally communicated with the HSE on this meeting, demanding that they have this matter dealt with in advance of our presentation. The NHI delegation that attended on the day were Tadhg Daly - CEO and Presenter, Denis Doherty- Chairman, NHI and Cora McNamara- NHI Board Director, NHI Please see weblink below to access transcript of meeting. This, along with a copy of presentation, can also be downloaded directly on - Members Area - The Joint Oireachtas Committee on Health and Children Congratulations to you all! aspx?f=hej xml&ex=all&page=1 NHI has lodged Formal Complaints to Ombudsman and Equality Authority NHI, over the last number of months have submitted a number of formal complaints to Local Health Managers and designated officers within the HSE re: availability of physiotherapy and chiropody services within private and voluntary NHI Member nursing homes. We received various responses back from the HSE confirming that they are not in a position to provide services to private and voluntary nursing homes. The NHI also submitted formal complaints, including all corresponding files from nursing homes and the HSE on this matter, to the Office of the Ombudsman and The Equality Authority, highlighting the discriminatory practices towards older people in nursing homes. We received responses from both parties acknowledging our letters, that they are currently investigating these issues and that they will revert back to us in due course. We will communicate with all members on this issue. Wound Management & Tissue Viability Resource Linda McDermott-Scales has been seconded to the HSE Inspectorate Team in Dublin Mid-Leinster for a year with a remit for Private and Public Older Person s Care Facilities. In 2003 Linda as part of a team developed a Nurse-Led Wound Clinic in Cherry Orchard Hospital and was employed as a Clinical Nurse Specialist in Tissue Viability. This non-domiciliary Nurse-Led service continues to provide a vascular outreach programme and an acute, chronic & complex wounds programme for community-based patients. Linda received a higher diploma in tissue viability in 2005 and an MSc in Nursing in She is passionate about the care of Older Persons, particularly those with wounds, and in nurturing evidenceinformed nursing practice to meet these patients needs. Linda organised a successful study day in the Kilashee House Hotel, on July 16 th entitled A Practical Approach to Standards in Wound Care. This study day was sponsored by Fannin Healthcare and available free of charge to nurses employed in HSE and Private Facilities. Due to the demand for this study day it is planned that it will be repeated in October. While Linda is unable to see individual residents on a one to one basis she is available as a resource on all aspects of tissue viability via . For any queries please contact linda.mcdermottscales@hse.ie Page 12

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14 ANNUAL CONFERENCE 8.30am 9.30am Thursday 13 th November 2008 Crowne Plaza Hotel, Dublin-Northwood, Santry, Dublin 9 Registration MORNING SESSION: Conference Chair 9.30am 9.45am 9.45am 10.00am 10.00am 10.30am 10.30am 11.00am 11.00am 11.30am 11.30am 12.00pm 12.00pm 12.30pm 12.30am 1.00pm 1.00pm 2.15pm John Bowman Welcome from Denis Doherty, Chairman NHI Opening Address, Mary Harney, TD, Minister for Health & Children Professor Brendan McCormack, Institute of Nursing Research/School of Nursing, University of Ulster Person Centred Care Programme and its implementation Clare Carroll, Carroll & Associates Impact of changing guidelines and regulations on the Cost of Care Tea/Coffee Opportunity to visit Exhibitors Dr Siobhan Kennelly, Liaison Registrar in Medicine for the Elderly, James Connolly Hospital Supporting Residents in Private Nursing Homes Brendan Little, Corporate Partnership Manager, DAS Group Legal Expenses Insurers Caring for your business Questions & Answers John Bowman, Chair LUNCH Sponsored by Medical Recruitment Specialists Opportunity to Visit Exhibitors AFTERNOON SESSION: 2.15pm 3.15pm John Hirdes, University of Waterloo, Canada Introduction to Minimum Data Set 3.15 pm 3.45pm Dr Marion Witton, Chief Inspector of Social Services, HIQA Standards for Residential Care Settings for Older People Remit of the Social Services Inspectorate & Nursing Home Inspections 3.45pm 4.15pm 4.15pm Questions & Answers John Bowman, Chair Conference Close Tadhg Daly, Chief Executive Officer, NHI Page 14 PLEASE NOTE: Conference attendance forms/brochures will be distributed to members shortly. Please contact Paula Lumsden on or admin@nhi.ie if you have any queries.

15 The Conference is the organisations single biggest event including speakers from both the domestic industry and International experts. NHI are particularly pleased to have John Bowman as Conference Chair. We are also honored that Mary Harney the Minister for Health and Children will give the opening address. Speakers Speakers including Brendan McCormack, Brendan Little, Dr. Marion Witton, Clare Carroll, John Hirdes, and Siobhan Kennelly, bring a wealth of knowledge to this conference and will provide invaluable information for the private and voluntary nursing home sector. John Bowman is a broadcaster and historian. He presents current affairs and historical programmes on RTE radio and television, including Bowman: Sunday Morning, the archives programme on RTE Radio One and Questions and Answers on RTE television. Mary Harney was appointed as Minister for Health and Children in September 2004, and reappointed following the 2007 General Election. Previously, she was Tánaiste and Minister for Enterprise, Trade and Employment from 1997 to 2002 and was re-appointed in June 2002, making history as the first woman to hold the title of Tánaiste and also to serve a second successive term. She served as leader of the Progressive Democrats Party from 1993 to She was Tánaiste and Minister for Enterprise, Trade and Employment from 1997 to Brendan McCormack, D.Phil (Oxon.), BSc (Hons.), PGCEA, RMN, RGN Professor of Nursing Research, Institute of Nursing Research, University of Ulster. Brendan is Professor of Nursing Research and Practice Development in the University of Ulster. He leads a number of practice development and research projects in Ireland, the UK, Europe and Australia that focus on the development of person-centred practice. In addition he is the leader of the Institute of Nursing Research Working with Older People. His writing and research work focuses on gerontological nursing and practice development. He is the co-editor of the International Journal of Older People Nursing. Brendan Little is the Corporate Partnerships Manager ROI at DAS Legal Expenses Insurance. During his 23 year career in the Insurance industry Brendan has gained Member of Society of Technician in Insurance (DipCII) and a Diploma in Financial Studies relating to Insurance (Dip Fin Ins). He started in the broking sector before moving to Ecclesiastical who specialise in Religious, Care Home, Community and Commercial Insurance, fulfilling a number of roles from Claims to Sales Account Manager. His DAS career began in 1999 as a Broker Account Manager. DAS are Ireland s and Europe s premier legal expenses insurer with over 150 offices in 16 countries and provide access to justice for millions of people. DAS insurance allows policyholders to exercise their rights by defending or pursuing a range of legal actions, safe in the knowledge that their legal costs and expenses will be covered. Dr Marion Witton, Chief Inspector of Social Services. Marion has a doctorate in Social Policy, She has many years experience of regulation of adults and children s care services and is widely respected within the field. As the Divisional Manager for the South East Region of the Office for Standards in Education, Children s Services and Skills Early Years Directorate in the United Kingdom (also known as OFSTED) she was responsible for the regulation and inspection of 20,000 children s day care providers. Prior to joining OFSTED, Marion was head of the joint inspection unit at the London Borough of Barnet, with responsibility for registering and inspecting residential care homes, nursing homes, clinics, independent hospitals, boarding schools and children s day care services. Clare Carrol is a partner in Carroll & Associates, Certified Public Accountants specialising in the Nursing Home sector. Clare carried out a study of Nursing Home costs in the private and voluntary sector in 1991, commissioned by the Department of Health. Carroll & Associates also provide consultancy services to Financial Institutions including collaboration on AIB publication A Business Guide to Nursing Homes with BDO Simpson Xavier. Consultancy work includes review of costs, profit margins and profit forecasts for private nursing homes John Hirdes PhD, is a Professor of Health Studies and Gerontology at the University of Waterloo. He holds cross-appointment to the University of Toronto, University of Guelph, McMaster University and University of Manitoba. Dr. Hirdes is the senior Canadian Fellow and a Board Member of interrai and led efforts to create the Method for Assigning Priority Levels in home care, and Home Care Quality Indicators (as co-pi). He is a member of the interrai committee that produced the new suite of instruments and care planning protocols, including the new interrai Long Term Care Facility (interrai LTCF) instrument and is currently leading a study to update the Resource Utilization Groups (RUG- III) case mix systems for nursing homes. Dr Siobhan Kennelly The Connolly Hospital Liaison Medicine for the Older Person service commenced in January The aim was to enhance provision of specialist care to older people at the site most appropriate to them. Dr Siobhan Kennelly, a Specialist Registrar in Medicine for the Elderly undertook to develop the service in conjunction with Dr Patricia McCormack (Consultant Geriatrician, Connolly Hospital), Connolly Hospital Management and HSE LHO North West Dublin Managers. The service aims to provide a seamless continuum of care between nursing home and acute hospital with particular emphasis on the specialist needs of the medically frail in nursing home care. Dr Kennelly s talk will discuss the development of the service and outline its experiences to date. Page 15

16 Valuing those who live to a ripe old age Proprietors and staff of Nursing Homes have a very good understanding of the abilities of older people as well as the disabilities and infirmities which often come with old age. They are aware of the advancing years at which older persons are now admitted to nursing homes and the expectations which they and their families bring with them. Older people are generally encouraged by the joys of living rather than the limitations on their abilities. A long life used to be regarded as a blessing. If achieving a ripe old age is to be celebrated, as we do with centenarians why do so many policy makers see the growing number of older people as a problem or as a matter of concern? To quote from a recent publication by a stage body Looking within the 65+ age group as they are of particular concern, the projections for those aged 65-74, and 85+ are also shown. As can be seen all age groups show a rise, however, in percentage terms the 85+ age group will increase by over 25% by 2011, over 50% by 2016, nearly 100% by 2021 and by over 400% by 2041 It was the words particular concern which caught my eye. Its use should be banned along with the term bed blocker and any other term which can be construed as implying negativity towards older people. If we are to prevent a long life becoming a dubious blessing we need to review our concept of ageing and old age. Rather than include all those over 65 years as older people I suggest that we should regard old age as commencing approximately five years before a person reaches the average life expectancy which is currently 76.7 for men and 81.5 for women. Men would be considered old at 71 and women at 76. As life expectancy increases the commencement of old age would also increase. Apart from the unhappiness at compulsory retirement at 65, or earlier for some employments, there are very practical reasons why we should redefine the point at which old age commences. Pension plans will become extremely expensive unless people are allowed to work longer. The recent drop in the value of pensions, and the changes being made by employers to pension schemes cannot continue to be ignored by the vast majority of people. A further factor is the potential cost of health insurance for older people. This is likely to become a topical issue as the full implications of the recent Supreme Court decision on risk equalisation in the health insurance market becomes clearer. Very many people have chosen to contribute to health insurance schemes in order to avoid the catastrophic consequences of ill health. They cannot insure themselves against the ageing process. For that reason we must collectively contribute to whatever schemes will enable people to avoid the catastrophic consequences of the infirmities of old age, including their financial consequences. The Fair Deal, in whatever format it is introduced and home care packages are only part of what is required. We need to face the reality that each of us must take some responsibility for ourselves so that we can minimise the financial cost of living a long life and add to the quality of our lives. One simple contribution is to take care of our health during all of our lifetimes and that we avoid health damaging behaviours. At a conference many years ago a speaker said that it would be too late to begin worrying about services for older people when we are rattling the cot-sides in a psycho-geriatric ward. While the terminology is outdated the underlying point is still valid. While there are many individuals and groups endeavouring to draw attention to the many aspects of ageing and the needs of older people it is time we had a joined up debate involving a much wider section of society. In the meantime we should prohibit references to the 65+ age group as being of particular concern and reaffirm the belief that a long life is indeed a blessing. We must not regard old age as a burden. If we value the people who live to a ripe old age, which I hope will include an increasing number of us, we will find the means to ensure that we have access to adequate pensions; affordable health insurance; a safe place to live and friends who will care for us. If you have no desire to do this for others do it for yourself. Changes can be expected in all services involving older people. These changes will take place faster than most people now realise. Nursing home proprietors need to look beyond the new standards and the Fair Deal and consider the implications of what is emerging. Martin Hynes (Martin Hynes is an Executive Director of O Cathain & Hynes, Strategic Advisors to the Residential Community Care Sector) Page 16

17 Investing in Staff, Securing our Future and Protecting our Residents A proposal for standardised induction It is well known that investing in staff has positive and lasting influences for patient care. Induction is a process whereby new staff have a structured and guided introduction to their new work environment. If carried out correctly an induction programme can both facilitate and consolidate learning to enable core competencies to be achieved whilst enabling clinical supervision and a welcoming approach to the new staff member. It can also help to retain staff and improve productivity. 1 In a changing environment where staff have a variety of skills, experience, and cultural and personal beliefs, induction is of the utmost importance to ensure care is provided in a seamless, standardised and professional manner. As registered nurses and employees we are all accountable for our own practice. An Bord Altranais (2000) state that In determining his/her scope of practice the nurse or midwife must make a judgement as to whether he/she is competent to carry out a particular role or function. The nurse or midwife must take measures to develop and maintain the competence necessary for professional practice. 2 By providing a structured induction programme which includes a competency framework the onus of learning and accountability is placed firmly on the employee. Nursing Homes Ireland Practice Development Facilitator Sinéad Fitzpatrick is working on an induction programme and clinical skills competency framework for all our members. The first draft is currently under consideration by the Nursing Committee. The programme is comprised of formal introductions and familiarity of the work environment including key policies and practices; non-clinical and clinical competencies for care of the older person using Benner s model 3 and formal appraisal and personal development planning. It is envisaged that the programme will be piloted in a number of homes for audit prior to full implementation. For further information contact Sinéad on sfitzpatrick@nhi.ie 1 Thomas, D (2006) Companies lose 2bn with poor induction strategies. Personnel Today 2 An Bord Altranais (2000) The Code of Professional Conduct for each Nurse and Midwife 3 Benner, P (1984) From Novice to Expert: Excellence and Power in Clinical Nursing Practice. MenloPark: Addison-Wesley Page 17

18 Just Because You Have Arthristis Doesn t Mean You Can t Exercise! - Arthritis Ireland Launch Unique Exercise DVD & Book - this programme certainly makes it easier. Both the book and DVD are very simple to follow and have enabled me to learn some specific exercises that have helped me focus on my problem areas - the results are really worth it! At the recent launch world-renowned adventurer and explorer Pat Falvey gave an insight into how to deal with the various challenges life presents and encouraged people with arthritis to conquer their personal Mount Everest of attaining better mobility and well-being through regular exercise. R Pictured at the launch of Arthritis Ireland s Be Active with Arthritis exercise DVD & book which is tailor-made for people with arthritis, is physiotherapist Emer McAuliffe, John Bennett (74), who has had rheumatoid arthritis since he was 30, Ruth Mann (58), who has had osteoarthritis since she was 46 and John Barnes (39), who has had ankylosing spondylitis, a form of arthritis, since he was 18. They all feature in the book & DVD, which will help people with arthritis to experience less pain and stiffness, improved flexibility and mobility, increased muscle strength and a better level of aerobic fitness and overall wellbeing. Be Active with Arthritis is a new exercise programme tailor-made by Arthritis Ireland for people with arthritis. This is the first of its kind, enabling people with arthritis to maintain and improve their mobility and overall well-being by using the step-by-step DVD or book in the comfort of their home. Many people with arthritis are afraid of exercising, however experts stress the importance of keeping joints flexible with some form of daily activity. The programme has been designed in consultation with physiotherapists who specialise in the area of arthritis and those who have followed it have reported that they experience less pain and stiffness, improved flexibility and mobility, increased muscle strength and a better level of aerobic fitness and overall well-being. Arthritis Ireland recruited the support of four people with arthritis to demonstrate the exercises in the DVD and book and is fronted by senior physiotherapist, Emer McAuliffe. Ruth Mann (58), who is one of these participants and has had osteoarthritis since she was 46 resulting in two hip replacements, says Exercise for people with arthritis can take some effort but Arthritis Ireland is dedicated to improving the quality of life of the 1 in 6 people who have arthritis, from toddlers right through to grandparents. They do this by providing practical support, information and advice and are delighted to now add this easy to follow exercise dvd to their support tools. They do note that the exercises in the programme are based on best practice, but warn that people should discuss their exercise plan with their GP or physiotherapist to rule out any reason why they may not participate. The book and DVD are available from Arthritis Ireland at a cost of 22 including post and packaging by calling or by visiting the online shop on All proceeds go to Arthritis Ireland to help make a difference to the lives of the 714,000 people with arthritis. Sarah Gahan, Communications Manager, Arthritis Ireland, t: Join Today Strength and influence in any sector comes through the combined voice of individual participants. We strongly recommend all nursing homes join. Nursing Homes Ireland Unit G6, Centerpoint Business Park, Oak Road, Dublin 12 T: (0) F: +353 (0) E: info@nhi.ie W: Page 18

19 Migraineurs can be elderly too It is rare for migraine to start in later life. At least 90% of migraineurs suffer their first attack before the age of 40 for most, this attack occurs during their teens and, more specifically, during puberty. This is not to say, however, that migraine does not affect the older generation. Last year, a review by the World Headache Alliance [WHA] discovered that while migraine is less common among the older population - those over the age of 60 do suffer. A 2004 study in the American Postgraduate Medicine journal put the figure at 7.5% of women over 65, and 2.5% of men. The WHA review found that the majority of this group only experience the visual (aura) symptoms of migraine, with an accompanying headache being less common. It was also highlighted that those who experience their first migraine attack after the age of 60, tend to have an underlying medical problem. Migraine in the elderly can also be easily confused with a transient ischaemic attack (mini-stroke) or vertigo and so can make diagnosis difficult. Carer, Mary O Brien *, told the Migraine Association of Ireland [MAI] that at the nursing home where she works, there is a patient who suffers from vertigo. However, her symptoms include an aversion to bright lights (she needs to Esker Lodge Celebrates as Winner of EIQA Nursing Home of the Year wear dark glasses), a general faint feeling and a headache three symptoms of migraine. We presumed when she joined us that she had vertigo but the more I think about it, the more it sounds like migraine. It s something we re going to have to look into, she says. Not only are there similarities, in terms of symptoms, to the aforementioned medical conditions, but links have also been revealed in countless studies not just to stroke and vertigo - but also to epilepsy and depression. This is a particularly important point to note for the carers of elderly people. The treatment of elderly migraineurs is also an area where a carer or medical professional must tread cautiously. For example, the most popular drugs for the treatment of migraine amongst the general population are known as triptans. However, the WHA advises that elderly people who are prescribed triptans should be regularly screened for heart defects as these drugs can cause cardiac side effects. Other popular treatments are also known to cause side effects in elderly patients and a medical professional should always be consulted before administering even the most basic analgesic (paracetamol, aspirin, ibuprofen, etc.) to an elderly migraineur. Therefore, preventative treatment is the safest path to ease the pain suffered. The Migraine Association of Ireland encourages sufferers to keep a migraine diary. The purpose of this diary is to identify trigger factors the factors that may set a migraine in motion. This advice extends to the elderly, or to their carers if the patient is incapable of keeping their own records. Carers are asked to pose such questions as: Is there is a particular food that the patient eats that triggers an attack? Does a migraine occur after a particular activity? In other words, carers are required to establish a cause and effect pattern and then to adapt the routine to avoid these causes. This, in theory, should lessen the frequency if not completely eradicate the migraine. The Migraine Association of Ireland can supply information to carers, medical professionals or elderly migraineurs. Simply call the helpline number for advice, information, further contacts or to join the organisation. Or check out our website at: * not her real name Donna Walsh Information Officer Migraine Association of Ireland At the end of last year Esker Lodge, Co. Cavan had a lot to celebrate. We secured planning permission for our extension, and more unexpectedly, we won National Nursing Home of the Year. The award was based on an EIQA audit which we decided to undertake as a way of identifying and implementing enhancements to our service. Because supply outstrips demand for beds, word of mouth is crucial. Therefore winning Nursing Home of the Year is a significant achievement at a local and national level. What set us apart, according to the EIQA, is best practice, i.e. activities that make our home unique. Our examples of best practice included: g A residents forum which identifies areas for improvement g A remembrance service every November for residents who sadly have passed away during the year g Training reflections after staff training to obtain feedback on the training received Of course anything worth doing is usually hard work and this was no exception. There were challenges. For example some staff were not convinced the project was a good idea. But when we won it gave everyone a sense of pride in the service we deliver every day. In our case the work involved to achieve the award was worth it because we have set our own standard for how we want to operate now and into the future. We relish the challenge to emulate our achievement again when we launch our new dementia unit and extension in Page 19

20 Commission on Patient Safety and Quality Assurance Report The Commission on Patient Safety and Quality Assurance was established in January 2007 with the remit to develop proposals for a health service-wide system of governance, based on corporate accountability for the safety and quality of health services. The commission is made up of a widely varied mix of healthcare professionals from the HSE, the CEO of HIQA, a GP, two patient/ carer representatives, a process engineering manager, quality and risk leads, head of clinical indemnity scheme, assistant secretary and deputy chief medical officer from the Department of Health and Children, and a regional director of public health for the southwest region of England. The Chairwoman is Dr Deirdre Madden, senior lecturer, faculty of law, University College Cork. The Commision s report entitled Building a culture of Patient Safety was launched on Thursday 7 th August The report has now gone to The Minister for Health and Children, Mary Harney to consider all the report recommendations with a view to bringing it to Government next month. A copy of the report is available at: b u i l d i n g _ c u l t u re _ p a t i e n t _ s a f e t y. h t m l The main recommendations of the report are summarised below: g Create a national network of patient advocates who will work in partnership with healthcare organisations g A public information service should be developed by HIQA and the HSE which makes information readily available to patients and carers when dealing with illness g Implement National Standards for open disclosure of adverse events to patients g Strengthen existing senior professional roles such as that of chief medical officer within the Department of Health and create new patient safety leadership roles within HIQA and the HSE g Professional regulatory codes of conduct (clinical and managerial) must make patient safety a priority as the primary duty of all health professionals g The chief executive within each defined healthcare organisation must be ultimately responsible and accountable for patient safety and quality within that organisation g Health service management teams should demonstrate competence-based training and be subject to ethical and disciplinary codes similar to other healthcare professionals g There should be mandatory licensing systems in the Republic to cover both public and private healthcare providers, including hospitals, primary and community care g The licensing function should be assigned to HIQA and the impact of licensing on patient safety be formally reviewed after three years g Private health insurers should require all private healthcare facilities to adhere to the new standards set by HIQA g A new group representing all professional regulatory bodies will develop plans for a first point of contact for patient concerns over clinical care, with referral as necessary to appropriate regulatory bodies g Create a system of alert notices for the exchange of information between healthcare employers in respect of health professionals for whom patient safety issues have arisen g A national mandatory reporting system should be introduced for the collection of standardised information on adverse events that result in death or serious harm g Professional regulatory bodies should include mandatory reporting of adverse events as an ethical obligation within their codes of practice g Validated patient safety data should be made available to the public in annual reports NHI s Practice Development Facilitator is currently looking at developing a reporting system for members in advance of the implementation of these recommendations. More information can be gained from Sinéad Fitzpatrick on Sfitzpatrick@nhi.ie or Page 20

21 Unique residential care facility opens in Meath Minister for Health Mary Harney performed the official opening of Redwood Extended Care Facility in Stamullen, Co. Meath on Friday 4 th July. Part of the Talbot Group of Care Facilities, which is a member of NHI, and owned by brothers Dr. Tony Woods and Mr. Michael Woods, Redwood is a purpose built 32-bedded specialised residential centre. It offers state of the art facilities to clients with an intellectual disability who may have challenging behaviour or other mental healthcare needs. It is the first of it s kind in the 26 counties. Redwood also provides a comprehensive assessment, treatment and rehabilitation service incorporating a specialised neurobehavioural rehabilitation unit. This specialised unit provides in-patient support to persons with an acquired brain injury and significant behavioural challenges. Located on a 70 acre estate in the village of Stamullen, Redwood offers peace and tranquillity and clients are encouraged to enjoy the grounds either by walking the nature trail, growing flowers or fruit and vegetables in the well equipped horticultural centre or by exploring their artistic side with the guidance of professional tutors. Clients are encouraged to develop their skills in an individualised programme and can achieve FETAC qualifications within the unit. Staffing levels at Redwood are high with 70 people employed. It is expected that 100 people will be working in the unit when it reaches capacity of 32 beds thus being a major R Pictured at the official opening of the Redwood Extended Care Facility were - Carmel Touey - Activities of Daily Living Instructor, Ray Flynn - Client -shaking hands with the Minister for Health and Children and Peter Dowling- Client. contributor to the local economy. Their areas of expertise include nursing, clinical psychology, occupational therapy, physiotherapy, speech and language therapy, health care assistants, community liaison, Montessori teacher, art teacher, horticulturalist, activities coordinator, psychology, neurology, GP, chiropody and nutrition. Proprietors Michael Woods and his brother Dr. Tony Woods have invested much time and money in this project and say We are delighted that the project has come to completion. We can now offer a highly specialised service led by a qualified professional team. Up until now this service has not been available in the 26 counties. We are happy to be able to deal with a cohort of clients who have significant behavioural problems allied to their intellectual disability or as a complication of an acquired brain injury. On behalf of Nursing Homes Ireland we would like to extend our congratulations and best wishes for continued success to Tony and Michael and all at the Redwood Extended Care Facility. A UNITED DRUG COMPANY ITRAVENO HEALTHCARE S RESIDENTIAL CARE DIVISION Prides itself on its ability to provide a comprehensive portfolio of high quality products for the nursing home and private hospital sector and is especially suited to those in the process of start up re: equipping or expanding existing facilities by offering a complete cost effective solution package with a wide range of options and styles to suit the budget. With over 25 years experience in servicing hospital equipment, Intraveno would be pleased to quote for service and maintenance over a wide range of products such as sluice equipment, beds, hoists and ancillary equipment. Products Available Include SLUICEROOM EQUIPMENT Sterilisers and Macerators ELECTRIC PROFILING BEDS FIRE RETARDANT CURTAINS AND BEDLINEN FURNITURE Bedside Lockers, Wardrobes, Dressing Tables HOISTS MOVING AND HANDLING EQUIPMENT LARGE SELECTION OF QUEEN ANNE, FIRESIDE CHAIRS AND SETEES INCONTINENCE Pads, Diapers and Draw Sheets Hygiene- Gloves, Bibs, Wipes Contact: Greg Ward Residential Care Division Manager Intraveno Healthcare, Unitech House, Magna Business Park, Magna Drive, Citywest Road, Dublin 24 Phone: Fax: Mobile: greg.ward@united-drug.ie SPECIALISING IN COMPLETE FIT OUT NEW OR EXISTING NURSING HOMES Page 21

22 Caring for the older person with diabetes Ten out of every 100 people over the age of 65 in Ireland have diabetes. In nursing homes, as much as half the residents will have diagnosed or undiagnosed diabetes. Symptoms of Diabetes The main symptoms of untreated diabetes or high blood sugars in older people are dry mouth, incontinence, sleepiness after main meals, blurring of vision and recurrent infections. Every person over 65 years of age should be tested annually for diabetes. A capillary blood sample may be used as a screening tool with normal levels being less than 6mmols fasting and 7 mmols after eating. If the levels are higher, a fasting and two hour post prandial blood glucose are warranted to confirm or out rule diabetes. Types of Diabetes Type 1 diabetes develops when there is an absolute lack (>80%) of insulin in the body.type 2 diabetes develops when the body produces some but not sufficient insulin to meet the demands of the body. High Blood Sugars Treatment of diabetes is to keep blood sugars near normal levels. High blood sugars in the short period can induce incontinence and infections and over a long period can lead to eye disease, heart problems, foot ulcers and high blood pressure. The life threatening nature of diabetes results from complications such as kidney failure, heart attacks and stroke rather than the condition itself. Treatment of Diabetes The treatment of type 2 diabetes is primarily taking a healthy eating diet, exercising as much as feasible, taking medications as prescribed and for approximately one third of people with type 2 diabetes, insulin therapy. Healthy Diet The diet for a person with diabetes is the same as the ideal healthy balanced diet for all. Diabetic foods are not necessary, are expensive and can cause loose bowel motions if taken in excess. Annual Check-up Each Person with diabetes should have at a minimum an annual Diabetes Review. This should include: g A review of their general health g Review of nutritional status and dietary recommendations g An opportunity to discuss any problems g Discussion on current blood glucose results and new targets set. g Recording of weight, height and blood pressure g Urine and blood tests g Eye examination not for vision acuity but checking for retinopathy g Review of injection technique and the places where insulin is injected, if on insulin g Feet should be checked for colour, temperature, feeling, and pulses g Discussion of overall results and what needs to be done before the next appointment Additional Resources Two useful booklets Food & Diet; Focus on Diabetes and Caring for Diabetes are available from the Diabetes Federation of Ireland helpline locall or can be downloaded from Also in-house training can be arranged for groups of 20 or more contact Cait Donnelly on cait.donnelly@diabetes.ie or Anna Clarke, Health promotion and Research Manager, Diabetes Federation of Ireland. Leading Healthcare Providers Skillnet is a new Skillnet in the private healthcare sector whose members are private nursing homes, 11 of the major private hospitals and home care sector. Imelda Duffy was appointed network manager in January 08 and has used her tutor qualifications and knowledge of the healthcare sector in getting courses accredited and delivered for LHP members in record time. The FETAC Level 5 Certificate in Healthcare Support is running in 5 centres around the country with 90 HCAs from member companies undertaking the Major award to date. The modules covered are Care Skills, Care Support, Safety & Health at Work, Communications, Work Experience, Care of the Older Person, Palliative Care Support and Team Working. Safe moving day and CPR certification are included. Feedback is excellent with great enthusiasm shown by all HCAs. The cost of the certificate to registered LHP members is very reasonable at 350. In this uncertain financial climate it is essential that LHP members avail of this excellent value for quality courses delivered by experienced RNTs while funding is available. New courses commencing in Athlone 3 rd Mullingar 12 th, Dublin 13 th Longford 17 th September, and Mallow in (DBA) September 08. For information on availability of places to any of the above forthcoming cost effective quality courses contact: LHP Network Course Planner - Annette Kelly at annettekelly@lhpskillnet.ie or Imelda Duffy, LHP Network Manager at or imeldadufy@lhpskillnet.ie The LHP Skillnet has been granted Category 1 An Bord Altranais approval for 11 courses for staff nurses. The Category 1 approved courses meet the criteria outlined in the National Quality Standards for the Residential Care Facilities,see The LHP Skillnet has obtained a not for profit licence from the University of Leeds to run LEO programme for network members in management positions. LHP Skillnet has run 2 very successful LEO programmes in Dublin and Athlone for multidisciplinary managers/leaders from 20 member business, a 3 rd programme commences in Gorey on 22 nd 23 rd & 24 th September. Important Date for LHP member s diary: The 1 st LHP Skillnet Annual Conference is planned for 9 th Oct in Killshee House Hotel, Naas. Inspirational Speakers on very relevant topics for all our members details going out to registered members, it is advisable to book early. The annual conference is free to registered members. The Bon Secours Hospital in Cork is a registered active member of LHP Skillnet and is the only private hospital in Ireland that has a Centre for Nurse Education. Catherine Flanagan, Director of the Centre has a number of excellent courses that are Quality Assured- FETAC Level (5), An Bord Altranais Category (1) Approved and Leading and empowered Organisation (LEO) approved by Leeds University. All LHP members in the Cork/Limerick/Kilkenny or other regions can avail of any of these courses at cost effective price. Contact the CNE directly on /4 to book places. Time table of courses for both the Centre for Nurse Education, Bon Secours Hospital and LHP Skillnet are available on the registered members site on The directors and steering committee members are all very clinically based professionals working in care and are very active in promoting, developing, and growing the network and supporting the network manager. Log on to for information on network, courses, membership application form. Page 22

23 Ombudsman welcome decision by HSE to reduce nursing home charges for elderly resident. On the 18 th of August the Ombudsman, Ms. Emily O Reilly, welcomed a decision by the Health Service Executive (HSE) to reduce the nursing home charge payable by the daughter of an elderly lady from 100 a week to 76. Commenting on the publication of a summary case report into a complaint lodged with her, the Ombudsman said: I want to put a spotlight on cases like this where waivers are granted by the HSE on grounds of financial hardship. I also want the general public and specialists working in the nursing home sector to be aware of this waiver in case they might know of people in similar circumstances who might also benefit. A weekly reduction of 24 in nursing home charges can make a genuine difference for someone on a low income and ease the burden of paying for nursing care. The specific details of the case are as follows: The Ombudsman was approached by a woman who had always provided care for her elderly mother in the family home. When this was no longer possible, her mother entered public nursing home care. A maximum weekly charge of 120, based on an assessment of her mother s financial circumstances, had been levied on her mother in accordance with the Health (Charges for In- Patient Services) Regulations, 2005, in respect of her nursing home care. The woman complained that, as a consequence of this assessment, she was finding it difficult to manage financially, as her mother s pension had previously formed part of the household income. The woman had already made an appeal to the HSE, and had provided copies of expenses incurred by both herself and her mother as proof of her financial difficulties. The HSE had acknowledged the possible hardship, and reduced the weekly nursing home charge to 100 per week. However, the woman had taken out substantial loans with the Credit Union, prior to her mother s admission to nursing home care, to adapt the family home for her mother s benefit. These adaptations had involved the installation of a stairlift and bathroom conversion. The woman explained that all the loans she had taken out, while in her name, were done on the understanding that her mother s income would help with the repayment costs. However the HSE Appeals Office stated that, since it was her name and not that of her mother s on the Credit Union account, this loan could not be considered for the purposes of obtaining a further waiver of nursing home charges. The Ombudsman felt that this was unfair given that the woman had done her best to provide care at home for her mother, and had taken out the home improvement loan for the purposes of maintaining her mother at home. She requested the HSE to review this case, having submitted the documentation regarding the loan and invoices showing the work which had been done. The HSE responded positively to her request, and agreed to further reduce the weekly charge to 76 per week, which was backdated to February, 2008, when the charges became applicable. Role of the Ombudsman The Ombudsman independently examines complaints about Government Departments and certain Public Bodies to help raise public service standards. Individuals, enterprises or organisations who feel they have been unfairly treated can lodge complaints to the Ombudsman. The service is free and impartial. The Ombudsman s aim is to ensure that people are treated with dignity, respect and sensitivity, in their dealings with the Public Service. We make every effort to deal with complaints in a proper, fair and understanding way. For further information telephone or / local or ombudsman@ ombudsman.gov.ie Telephone contact: E mail: info@corestaffing.ie Web page: Page 23

24 National Nursing Home Training & The word Home has a certain shared meaning for all of us usually as a place of warmth and comfort for ourselves and our families. A place of familiarity, safety and loving and supportive relationships, surrounded by people who are close to us. Home for ten s of thousand s of older people in Ireland is a nursing home. The source of most of their safety, warmth and support in their home, in a lot of examples, comes not from their families but from care-givers. Care Assistant staff, Nursing staff, Household staff, Kitchen staff, Therapy staff and Doctors. Combined these care-givers provide millions of hours of dedication and support, not only directed at caring for older people in nursing homes but in providing a caring and supportive homely environment for older people in nursing home care. Quality Initiative The National Nursing Home Training & Quality Initiative (NNHTQI) has been established to enhance the quality of life of older people in nursing homes - both in the private and public sectors. The NNHTQI project aims to deliver consistent improvements in older person s quality of life experience in residential care. The project is being run on a pilot basis with twelve nursing homes so far participating in the pilot scheme - six in the private sector and six in the public sector. The participating nursing homes are spread across the country, including members of NHI. NHI are represented on the steering committee for this Initiative. There are two distinct strands to the project. The first involves delivering a programme of FETAC training (levels 3, 4, 5 and 6) aimed at care-givers within the nursing homes selected for the pilot scheme. This training will be reinforced with clinical assessment interventions to ensure a transfer of skills from the classroom to the bedside. Training is delivered in a flexible manner that takes into account staff and nursing home preferences and is conducted on-site in the nursing home. To date the project has delivered significant levels of training in private nursing homes with training in public nursing homes expected to commence in October. Six Fetac training classes are currently underway as part of this project. A further two classes are due to commence in September for Fetac level 6 (supervisory) training. There are now 63 trainee s in the system as part of this project with a further 15 / 16 starting in September. This represents the first phase of the training. Within the private nursing homes 133 mainly support staff expressed interest in training. Not all staff who expressed an interest in being trained can be accommodated as part of the initial phase but should expect to be accommodated in subsequent training phases with a view to achieving overall critical mass in relation to training within nursing homes participating in the project. R On on-site Fetac training course in Cuil Didin Nursing Home Tralee. Picture shows Amanda Prendiville, Agata Nowik, Jamie Kelly, Marta Jancia, Jona De La Cruz, Niamh Foley Kerry VEC Tutor, missing from picture Winnie Plata The second strand of the NNHTQI project involves identifying, developing and implementing a range of initiatives aimed at improving the level of residential care and quality of life for residents of nursing homes. Four distinct themes have been identified as being central to the quality of life for residents in nursing homes - g Resident Independence & Autonomy; g Maintaining Personal Identity & Sense of Self; g Maintaining Connectedness & Social Relationships; g Engagement in Meaningful Activities. A number of culture change and quality initiative interventions that relate to each of the Quality of Life themes listed above have been identified and outlined. These are being implemented in each of the Nursing Homes involved in the NNHTQI project through locally based partnership implementation groups representing a cross-section of staff at the Nursing Home. The focus of the partnership implementation groups is partnership and collaboration between all staff and residents with the objective of making quality of life improvements for nursing home residents. Control and leadership of the partnership implementation groups comes from the staff themselves, and they are supported by the project manager. Some examples of quality initiatives currently underway include: RPicture shows part of the Enhanced Dining setup in St.John s Enniscorthy g Life stories; g Reminiscing with residents; g Fine dining on a Sunday with alcohol; g Personal preference birthday cakes, sometimes with parties; g Pictorial menus; g Accessing the community on a regular basis; g Spending regular quality time with residents. About the Author: Christopher Cullen is Project Manager of the National Nursing Home Training & Quality Initiative, an initiative co-sponsored by the HSE and the Health Services National Partnership Forum (HSNPF). He is an independent, Irish Project Management Institute (IPMI) certified project manager with experience of health and donor funded projects both in Ireland and overseas. Page 24

25 Case Study on Demonstrating Benefits of ACT Course - Denis Harrington and I, Ann Crowley completed our course in Activity in Care Training (A.C.T.) in June We enjoyed the course and gained new knowledge skills and abilities that we put into practice with the group of residents we had been working with and continued to do so. However we were aware that there was a group of residents that did not get involved in any activities within the Home. This was our challenge. Denis and I discussed this group with our CNM s 2 Colette Culver and Mary O Mahony. They gave us all the help and encouragement to set about creating a class for the visually impaired. With the bit between our teeth, we were off organizing Health and Physiotherapist Clearance Forms and Risk Management forms for the six residents in the Home that are visually impaired. We went on a trip to the seaside to get sand, shells and pebbles for one of our sensory boxes. We also made another sensory box containing household objects i.e. a clothes peg, a small ball, a soft toy, a ball of wool, a comb, a biro, a notebook etc. A class plan was drawn up, keeping in mind the safety and welfare of our group. We went and met the residents and invited them to join in the proposed class, which they all agreed to. We also met their families so as to keep them informed. A date was set and now it was up to us to make a success of it. The music is so important for the visually impaired, so we went for soft background music as not to distract from our verbal instructions. THE GOALS FOR THIS GROUP: Is to improve the ability to perform basic A.D.L. s CLASS PLAN: g Simple warm up g Soft ball activity/game g Introduce sensory boxes g Cool down g Chat We gathered on the set date and sat in a circle so that everyone could easily hear our instructions and Denis slowly did the warm up and explained each movement that we were about to do. I (Ann) did the activity phase, soft ball held it in their hands, rolled it, squeezed it and so on. Then I introduced the sensory box and this proved to be good fun as we laughed at some of the comments. Then we had the cool down phase. This involves stretching for the muscles and finished off with relaxation and a chat. We gathered feedback on the session and felt comfortable in the group. We finished off our chat with a song from one of the residents and they all agreed to attend again next week. We thanked everyone for attending. PROGRAMME GOAL: To maintain or improve their ability to perform basic A.D.L. GROUP NEEDS: Activities to improve balance and posture include activities which have social interaction, promote relaxation. BENEFITS: Creates fun, jogs memory, encourages movement, singing and clapping, good social interaction. We have learned that physical activity sessions have given us a new approach to working with the older person and as leaders of physical activity we have become more aware of the residents needs and to keep the exercise programmes simple and repetitive in a safe and risk free environment. I would like to thank: Julia Horgan, Director of Care Colette Culver, CNM 2 Mary O Mahony, CNM 2 Eugene Browne, Residents Advocate All the staff nurses and care staff in each of the units. I would also like to thank the A.C.T. Course Team and Mary Cowman for her advice and encouragement. I would particularly like to thank Nursing Homes Ireland for organizing the courses and helping to arrange funding. By Ann Crowley Act Leader St. Lukes Nursing Home The success of the ACT course has been widely demonstrated within this article and due to the responses and requests for further training. The Activity in Care Training (ACT) Programme was developed by the Centre for Health Behaviour Research in the Department of Health, Sport and Exercise Science, Waterford Institute of Technology in collaboration with the Health Promotion Department of the SE Health Board. The ACT programme provides staff in long stay facilities for older adults with the skills to design suitable chair-based physical activity sessions for frail older adults. The activities used in the programme aim to enhance range of movement, balance and co-ordination, strength, mental stimulation and social interaction among the participating residents. Examples of the activities used include light mobility exercises, ball games, parachute games, stretching, mental activity games and socialisers. Participants who successfully complete course requirements are awarded a certificate by the Department of Adult and Continuing Education in the School of Education and Professional Development, W.I.T. Since February 2007 we are pleased to say that four ACT courses have been offered to members of Nursing Homes Ireland (NHI) in the Cork, Limerick, Kerry and Galway regions through FAS Services to Business, Southern and Western regions. A further course is due to take place in Roscommon commencing 1 st October Each of these courses has been funded by the Irish Government and part-financed by the European Union under the National Development Plan, South West Skillnet have also kindly agreed to fund two courses in Kilkenny commencing 8 th October 2008 and in Dublin in November For details of the course, further information and booking please info@nhi. ie or telephone Head Office on (01) Martha McGinn Training and Consultation Ph: Mobile: mmcginn@iolfree.ie Web: Are you a Nursing Home Owner / Manager? Want to take the worry out of the HIQA Standards? Are you responsible for implementing the HIQA Standards? Then we can help you:- Build a compliant, capable and competent staff group with certified training Manage behaviour which is challenging using best practice methods Develop a Care Planning System which meets HIQA Criteria and Standards? Increase your nursing homes capability to develop policies and practices to comply with HIQA Standards? Look at the variety of methods of training programmes we can provide for you: In-house training Certified training, FETAC, An Bord Altranais, ILM Direct taught and distant learning programmes Highly experienced and professional tutors FAS Funding may be available Testimonials: Staff found the training very relevant to their role and the group they cared for Sean Molloy DON Bloomfield Nursing Home Rathfarnham Dublin. Provided staff with a clear direction in the management and implementation of care plans Bridie McGroary Fletcher DON St. Monica s Nursing Home Dublin. Martha provides high quality evidence based training in order to comply with the National Quality Standards in Residential Care Settings for Older People. Further information is available at which includes further testimonials to the high standard of training which she provides. Don t know where to start then let us undertake a Training Needs Analysis and design a package of training tailored to meet the needs of your staff team. CALL NOW AND GET YOUR FREE CONSULTATION Page 25

26 Staff Want Involvement in Policies and Procedures - New Research Findings A recent study carried out by Pamela Fagan, Director of Quality with Health Care Informed, has identified that nursing home staff that are directly involved in the development of policies and procedures are more interested in implementing the resultant improvements. This study reviewed the introduction of largescale change to a residential unit. The large-scale change involved the introduction of controlled documentation and defined processes, in the form of a policies and procedures framework, into all areas of the organisation, in an attempt to introduce a quality culture to the organisation. It was anticipated that such change may encounter resistance from staff, thus stakeholder involvement was a key priority at all stages of the project. From Friday 26th of September to Saturday 4th October 2008 Age Action with the support of ESB Customer Supply is Celebrating Positive Ageing in Ireland. Positive Ageing Week is a festival which highlights the positive aspects of ageing and celebrates the contribution older people have made and continue to make to their communities. To mark this contribution Age Action are asking individuals and groups to organise events and activities to celebrate the week. This is the 6 th year Age Action has marked UN International Day of Older Persons (1 st October) and each year Positive Ageing Week has become bigger This study attempted to evaluate the success, or otherwise, of this strategy. A self-administered questionnaire was developed by Health Care Informed, and completed by 52% of the relevant population. Results indicated that there was overwhelming satisfaction with the involvement in the change process, and that 100% of respondents agreed that being involved would make it easier for them to make the necessary changes. However, key information was also received regarding concerns of the participants. Predominantly through qualitative feedback, the participants noted concern at the ongoing and longterm implementation of the changes. While they Positive Ageing Week and better. Last year there were 450-recorded events and this year they are hoping for at least 600, including many from across the border. Events held included coffee mornings, quiz nights, bowling, arts & crafts workshops, performances, information talks, musical evenings etc. In addition to the 600 individual events expected to take place during the week, 10 towns have been selected to be Positive Ageing Week Towns, they are Athy, Midleton, Galway, Arklow, Drogheda, Kilkenny, Dungarvan, Sligo, Mountmellick, and Dublin city. Each town will host a week-long series of events. expressed satisfaction at the introduction of the changes and their involvement in same, they were concerned that the maintenance of these changes may prove difficult. Results from this study indicate that involvement of stakeholders in the instigation of a major change is hugely beneficial to overcome anticipated resistance to change and to improve stakeholder acceptance and understanding of the change. However, priority must be given to the ongoing implementation and maintenance of the changes if the long-term success of the project is to be achieved. For more information please contact: Ms. Pamela Fagan, Director of Quality. pamela.fagan@ hci.ie Age Action encourages every community to organise an event during Positive Ageing Week to celebrate the fact that we are living longer and that ageing is not a burden but an opportunity. For a Positive Ageing Week information pack please contact Lorraine Murphy on or lorraine.murphy@ageaction.ie or log onto wwwageaction.ie and enter details of your event online. If you would like to get involved and support events that are happening in your area during Positive Ageing Week please log onto wwwageaction.ie or phone for a full list of events. Page 26

27 Autumn 2008 Sonas Workshops Course description Dates Venue Duration Sonas workshop - Cork Sonas workshop - Galway Sonas workshop - Dublin Training and Education Wednesday 17 th September & Wednesday 12 th November 08 Tuesday 23 rd September & Tuesday 11 th November 08 Thursday 23 rd October & Thursday 27 th November 08 Sonas is a therapeutic activity for older people with dementia, including Alzheimer s, and others who have some type of communication impairment. It is delivered through group and individual sessions which involve sensory, social and cognitive stimulation. The aim is to activate each participant s potential for communication, thereby enhancing their quality of life. We train care assistants, nurses and other healthcare workers to implement this approach in their workplaces. Full Sonas training, which involves the two day workshop plus a third training day and assessments, is a FETAC Level 5 module. Sonas apc, an approved FETAC Centre and registered charity, was awarded its FETAC QA Certificate in Several skillnets provide their members with funding towards our training. Private Healthcare Skillnet provides grants of up to 50% and Leading Healthcare Providers offers our module as part of its FETAC Level 5 Healthcare Support Certificate. To book a place on one of our courses or for more information, please contact the Sonas apc office at or us at sonasapc@iol. ie. Comprehensive information and the latest workshop dates are also available on our website, at ACT Courses: NHI are pleased to announce the following Activity in Care Training Courses to be held in conjunction with Waterford Institute of Technology, FAS and Southwest Skillnet. Courses to be run in Roscommon, Kilkenny, Cork & Dublin. Roscommon Week 1 begins 1 st Oct. Venue: Sonas Care Centre, Lisgallon, Cloverhill Co Roscommon. Kilkenny Week 1 begins 8 th Oct. Venue: Brookhaven NH, Donoughmore, Ballyragget, Co. Kilkenny. Cork Week 1 begins 4 th February Venue: St Luke s, Dublin Blackrock (to be confirmed) Week 1 begins 14 th January 2009 TBC. Venue: TLC Centre, Northwood Park, Santry Demesne, Santry, Dublin 9. Each course requires a minimum of 12 people to be viable and can take up to a maximum of 20 people therefore interested applicants should book immediately through head office on or by ing info@nhi.ie to ensure all courses run as scheduled. The Victoria Hotel, Patrick Street, Cork The Victoria Hotel, Victoria Place (near Eyre Square), Galway St Mary s Centre, 201 Merrion Road, Dublin 4 2 full days ( pm each day) 2 full days ( pm each day) 2 full days ( pm each day) Our Lady s Hospice Limited, Education and Research Centre also deliver on-site education and training to various organizations. Specific training needs are identified in consultation with you, and an education/ training package is designed to suit the local organization. Further Details: Our Lady s Hospice Limited, Education and Research Centre, Harold s Cross, Dublin 6w T / 806 F E education@olh.ie W The following courses on offer are tailored towards Older Person Care and many of them are essential for Activity Co-ordinators. Introduction to Rheumatology for Registered Nurses & Allied Health Professionals Sept 2008 Working With People Who have Behaviours That Challenge (2 Days) 22 Sept/4 Nov Update in Best Practice In Older Person Care (1 week) 6 10 October 2008 Activities for People With Dementia 7 October 2008 Essential Role of Sensory Stimulation in Older Person Care 5 November 2008 Palliative Care for the Older Person (Nursing Homes) 4-5 December 2008 NHI, in conjunction with Fresenius Kabi, Education Days on Nutrition, Hydration and Dysphagia Policies g 23 rd September Citywest Hotel, Dublin g 30 th September Maryborough Hotel, Cork g 9 th October - Claregalway Hotel, Galway For booking details please contact info@nhi.ie or Upcoming Events g Sept 18 th Irish Hospice Foundation Coffee Morning If you would like to host a coffee morning or get involved in some other way, contact your nearest hospice fundraising group. Alternatively, you may call the Irish Hospice Foundation on , or tracy.power@hospice-foundation.ie g Sept 21 st World Alzheimer s Day Alzheimer s Disease International Ph: info@alzheimer.ie g Sept 25 th SFA Annual Conference Phone: aisling.igoe@ibec.ie g Sept 26 th -Oct 4 th Positive Ageing Week 2008 Age Action Ireland Phone: info@ageaction.ie 08.asp. Please also see page 26 g Oct 1 st International Day of Older Persons Phone: info@ olderinireland.ie g Oct 6-12 th National Arthritis Week Arthritis Ireland Phone: info@arthritisireland.ie g Oct 17 th Evidence for Healthcare Reforms, The Health Systems Research Centre Annual Conference 2008 will be held on Friday 17 th October 2008 in the Castle Oaks House Hotel, Castleconnell, Limerick g Nov 3 rd Our Lady s Hospice Limited, Annual Gerontology Conference The aim of this year s conference is to provide participants with an opportunity to reflect on the benefits of the provision of therapeutic interventions in care of the older person settings. Further Details: Our Lady s Hospice Limited, Education and Research Centre, Harold s Cross, Dublin 6w T / 806 F E education@olh.ie W g Nov 13 th NHI Annual Conference please see page 14 & 15 for more information on schedule of events, speakers, venue and booking details. g Nov 14 th World Diabetes Day Diabetes Federation of Ireland Phone Page 27

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